Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F Telephone: (209) 466-6781 ,, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> -76•-/,o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued i1- -7Z <br /> (Complete In Triplicate) `--- <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ -- mak C'e I eL� Phone --3 � <br /> Address City <br /> Contractor's Name License ���7`;'Phone - <br /> TYPE OF WORK (Check) : NEW WELL/ . DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION )<—PUMP REPAIR/ / PUMP REPLACEMENT /7 1 <br /> Other / ! <br /> DISTANCE TO NEAREST: SEPTIC TANK,,� _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE-V PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL { <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS <br /> Industrial Cable Tool Dia, of Well Excavation - 010 <br /> fit-- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _._ 4$ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical.. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor G <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: . / / State Work Done j <br /> PUMP .REPAIR: / / State Work Done <br /> i <br /> DESTRU_C_TION OF WELL: Well Diameter Approximate Depth t <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District t <br /> and the State of California pertaining to. or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a ; <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above i <br /> information is t e to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AND IN CT <br /> SIGNED TITLE j <br /> •I( RAW PLOT PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ' { <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I FINAL INSPECTION <br /> INSPECTION BY - DATE` INSPECTION B DATE �L+T <br /> i <br /> E ;H .1.)+26 Rev, J-74 µ �' A 3/76 2M yfi <br /> ., Y;' _ 1 <br />